Simon Eaton, Northumbria Healthcare NHS Trust, UK; Dr. Glenda Parmenter, University of New England; Catharine ... Dieticians. ⢠Community Health Managers ...
Faculty of Health
Looking after yourself: Understandings of chronic-care self-management models in rural and urban contexts of UK and Australia
Professor Penny Paliadelis, Federation University Australia, Ballarat, Australia; Professor Susan Carr; Monique Lhussier; Natalie Forster, Northumbria University, UK; Simon Eaton, Northumbria Healthcare NHS Trust, UK; Dr. Glenda Parmenter, University of New England; Catharine Death, Hunter New England Health District, NSW, Australia
Faculty of Health
These projects explored how health professionals involve clients with chronic conditions in managing their own care. Rural setting, Northern Urban setting, Northern UK NSW, Australia
Overview of the two qualitative studies UK Individual interviews with 13* healthcare practitioners: • General practitioners • Nurses • Practice Managers *Plus a training day for 18 healthcare practitioners on the operationalisation of selfmanagement was observed by the researchers and notes were taken and added to the qualitative data.
Australia 3 focus groups (each with 10-15 participants) with a range of healthcare practitioners: • Nurses • Medical Staff/General Practitioners • Social Workers • Dieticians • Community Health Managers
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Shared Questions
Australia and UK • ‘Could you explain your understanding of patient or client self-management as a concept and how you implement it?’ • ‘What drives the way you enable people with chronic conditions to self-manage their own health-care needs?’
Key themes – a synthesis of the findings Theme 1: Models of Care •
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Changing service aims -trends to shared-decision making and client-centered approaches to care. Rebalancing of client/health professional relationships. Economic pragmatics and the cost benefits of effective selfmanagement.
‘The health system has always been about the need to ‘fix’ peoples’ health problems, with little acknowledgement that patients could play a bigger part in understanding and managing their own health’. ‘It’s all about bangs for bucks, I think that if we intervene early we’re more likely to make a difference … once you’ve gone beyond those first few years or couple of years of diagnosis, patients have quite fixed beliefs about their condition’.
Theme 2: Barriers and enablers to supporting self-management •
SUB-THEMES
• •
Disease-specific factors Rural context
‘I go to see a client and they do open up about so many other things that impact on all their chronic diseases, but inflexible models don’t allow you to challenge the disease-specific sort of approach’. ‘I ask them [the clients] what they want to work on, because they’re not going to hear what you pick as the most important thing for them. You’ve got to tap into what they think’s the most important, regardless of whether it fits with the care plan for diabetes’. ‘The other thing that poses opportunity for us rurally is that while we do have limited resources in some places and, you know, limited capacities because workforce might be very, very thin on the ground. So we have to work together for the whole of community to be able to maximise what they can get within the community’.
Theme 2: Barriers and enablers to supporting self-management • • •
SUB-THEMES Perceptions of client readiness Identity, role and skill set of the practitioner
‘As health professionals we tend to go in and hit them with the knowledge and expect that if we give them all this information that they’ll do what you tell them to do. Then you wonder why you get so frustrated when they don’t do as you say and they come in year after year and their condition get worse’. ‘Younger people sometimes make poor choices then expect the healthcare system to ‘fix’ their mistakes. This leads to a climate of blaming non-compliant clients’. ‘There’s certain people in the practice who I can imagine will find that new way of working quite difficult to take on board.’ ‘I kind of feel responsible if they don’t listen and act on my advice.’
Theme 3: Political contexts Uncertainty over political commitment to supporting selfmanagement. Healthcare reform agendas. Changes in government.
‘I suppose because of the political climate, we’ve got to be careful, I know this is a pilot and we’re being paid to be part of the pilot and we need to feed into that but what’s the landscape going to look like later?’ ‘So many different levels of service that are funded to provide different things. I hate to think how much resources and billions of dollars going into renal and diabetic and cardiac, you know? It would be good if it was pooled together and translated into healthier patients … cos it’s not sustainable’.
Conclusions An overwhelming desire to enable and empower clients to self-manage. A need for integrated and sustained health policies and funding models. Tensions around the traditional discourses of health practitioners (to deliver care), and health systems that traditionally ‘fix’ problems. Supporting/educating clients to make informed choices v. expert knowledge and accepting patient choices that don’t ‘fit’. Better education and support for health practitioners to become facilitators of self-managed care.
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Reflection - While these studies do not provide a national or international commentary, there were striking similarities.
The final reflection on these studies is that there was a clear awareness that while self-management is widely represented as a learning process for clients, in reality, it is just as much a learning process for clinicians. They are the ones who need to work within a climate of constant healthcare reforms, to support patient choices, even if these don’t ‘fit’ their ideas of optimal care.
References Australian Government 2011 National Health Reform –Improving Primary Health Care for all Australians, Commonwealth of Australia, Canberra. Blakeman, T., Bower, P., Reeves, D. & Chew-Graham, C. 2010 ‘Bringing self-management into clinical view: a qualitative study of long term condition management in primary care consultations’, Chronic Illness, 6, 136-150. Baumann, L.& Dang, T. 2012 ‘Helping patients with chronic conditions overcome barriers to self-care’, Nurse Practitioner,37(3), 32-38. Bayliss,E., Bosworth,H., Noel,P., Wolff, J., Damush, T. & Mciver, L. 2007 ‘Supporting self-management for patients with complex medical needs: recommendations of a working group’, Chronic Illness, 3: 167-175. Carr, S., Paliadelis, P., Lhussier, M., Forster, N., Eaton, S., Parmenter, G. & Death, C. 2014 ‘Looking after yourself: Clinical understandings of chronic-care self-management strategies in rural and urban contexts of UK and Australia. SAGE Open Medicine, DOI: 10.1177/2050312114532636 Kennedy, A., Rogers, A. & Bower, P. 2007 ‘Support for self-care for patients with chronic disease’, British Medical Journal, 335,968-970. Kendall, E., Ehrlich, C., Sunderland, N., Muenchberger, H. & Rushton, C. (2011) ‘Self-managing versus self-management: Reinvigorating the socio-political dimensions of self-management’, Chronic Illness, (7): 87-98. Lhussier M, Eaton S, et al. (2013). "Care planning for long term conditions – a concept mapping." Health Expectations http://onlinelibrary.wiley.com/doi/10.1111/hex.12063/pdf.
Paliadelis, P., Parmenter, G., Parker, V., Giles, M. & Higgins, I. 2012 ‘The challenges confronting clinicians in rural acute care settings: A participatory research project’ Rural and Remote Health Research, Education, Practice and Policy, 12(2):1-12. NHS England (2013). Transforming participation in health and care. http://www.england.nhs.uk/wp-content/uploads/2013/09/trans-part-hc-guid1.pdf 10. NSW Department of Health 2008 Clinical Services Redesign Program: Chronic Disease Self-Management Support, NSW Department of Health, North Sydney
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Thank you! Questions and Comments? Rural Australia
Urban UK
NOT so very different!
